HELMINTHS

Platyhelminthes (Flatworms)
A. Cestodes (Tapeworms)
- Taenia (pork and beef)
- Diphyllobothrium (fish)
- Echinococcus (dog)

B. Trematodes (flukes)
- Schistosoma (blood)
- Clonorchis (Asian liver fluke)
- Paragonimus (lung)
Cestodes
2 main parts
- Rounded head (scolex)
- Flat body consisting of multiple segments (proglottid): worm grows by adding new
proglottids from its germinal center next to the scolex; oldest proglottid at the distal end
are gravid and produce many eggs, which are excreted in the feces.
1a. Taenia Solium (pork tapeworm)
Disease
- Taeniasis – adult ; cysticercosis – larvae
Important Properties
- Scolex – four suckers and a circle of hooks
- Adult tapeworm is located in the human intestine – occurs when humans are infected
by eating raw or undercooked pork containing the larvae (cysticerci)
- Larvae attach to small intestine wall and grow into adults in about 3 months
- Gravid terminal proglottids containing many eggs detach daily, passed into the feces,
and are accidentally eaten by pigs
- A six-hooked embryo emerges from each egg in the pig’s intestine, burrows into a blood
vessel and carried to skeletal muscle where they develop into cysticerci
- Humans – definitive hosts
- Pigs – intermediate hosts
 - Cysticercosis
 Person ingests the worm eggs in food or water contaminated with human feces (not
by ingesting undercooked pork)
 Eggs hatch in the small intestine and burrow through the wall into a blood vessel,
disseminating into the eyes, skin, and brain, forming cysticerci
Pathogenesis
- Adult tapeworm causes little damage; cysticerci can become very large and manifest in
the brain as a space-occupying lesion
- Living cysticerci do not cause inflammation but upon death release substances that
induce inflammatory response and calcify
Clinical Findings
- Adult tapeworms – asymptomatic; anorexia and diarrhea may occur; proglottids in stool
- Cysticercosis – brain: headache, vomiting, seizures; eyes: uveitis, retinitis, floating
larvae in vitreous; subcutaneous nodules; cysts found in skeletal muscle
Laboratory Diagnosis
- Gravid proglottids with 5-10 primary uterine branches in the stool
- Eggs are found less often in stool
- Cysticercosis – demonstrating the presence of cyst in tissue by surgical removal or CT
scan
Treatment
- Praziquantel
- Cysticercosis – praziquantel/albendazole, surgical excision
Prevention
- Cooking pork adequately, disposing waste properly, proper hygiene including
handwashing
1b. Taenia Saginata (beef tapeworm)
Disease
- Taeniasis; no cysticercosis in humans
Important Properties
- Scolex with four suckers; no hooklets
- Life cycle similar to T. solium (ingested by cattle)
Pathogenesis
- Similar to T. solium
Clinical Findings
- Adult tapeworms – asymptomatic; malaise and mild cramps can occur; proglottids
appear in the stools and may even protrude from the anus; proglottids are motile and
may cause pruritus ani
Laboratory Diagnosis
- Gravid proglottids with 15-20 uterine branches in the stools; eggs found less often
Treatment
- Praziquantel
Prevention
- Cooking food adequately and disposing waste properly
2. Diphyllobotrium latum (fish tapeworm)
Disease
- Diphyllobothriasis
Important Properties
- Instead of suckers, 2 elongated sucking grooves for attachment to intestinal wall
- No hooks, proglottids are wider than long, gravid uterus in the form of rosette
- Eggs are oval and have a lidlike opening at one end
- Longest of tapeworms (up to 13 m)
- Caused by ingesting raw or undercooked fish containing larvae
- Larvae attach to the small intestine wall and develop into adult worms
- Gravid proglottids release fertilized eggs and are passed in the stool
 - Eggs are deposited in fresh water and develop into embryos; eaten by tiny copepod
crustacea (first intermediate hosts) – differentiate and form procercoid larvae in the
body cavity
- Copepod is eaten by the freshwater fish and larvae differentiate to plerocercoids in the
muscle of the fish (second intermediate host)
Pathogenesis
- Causes little damage in the small intestine
- In some individuals, B12 deficiency occurs because of preferential uptake by the worm
Clinical Findings
- Asymptomatic; abdominal discomfort and diarrhea can occur
Laboratory Diagnosis
- Oval, yellow-brown eggs with operculum at one end in the stool
Treatment
- Praziquantel
Prevention
- Adequate cooking of fish and proper disposal of human feces

3. Echinococcus granulosus (dog tapeworm)

Disease
- Echinococcosis; larvae causes unilocular hydatid cyst disease
Important Properties
- Composed of a scolex and only 3 proglottids (one of the smallest tapeworms)
- Scolex: circle of hooks and four suckers
- Dogs are the most important definitive hosts
- Intermediate hosts – sheep; humans (dead-end intermediate hosts)
- Worms in the dog’s intestine liberate thousands of eggs – ingested by sheep (or
humans); embryos emerge in the small intestine and migrate primarily to the liver but
also to the lungs, bones and brain
- Embryos develop into fluid-filled hydatid cysts, the inner germinal layer of which
generates many protoscoleces (larvae) within brood capsules – slaughtered sheep are
eaten by dogs
Pathogenesis
- Echinococcus granulosus usually forms one large fluid-filled cyst (unilocular) that
contains thousands of individual protoscoleces as many daughter cysts within the large
cyst
- Individual protoscoleses lying at the bottom of the large cyst are called “hydatid sand” -
acts as a space-occupying lesion
- Outer layer is thick, fibrous, tissue; cyst fluid contains antigens that can synthesize the
host
- Upon spontaneous rupture or surgical removal, may induce anaphylactic shock or
spread widely
Clinical Findings
- Asymptomatic; liver cysts may cause hepatic dysfunction; cyst in the lungs – bloody
sputum; cerebral cysts – headache, focal neurologic signs;
Laboratory Diagnosis
- Microscopic examination demonstrating brood capsules containing multiple
protoscoleces; serologic tests
Treatment
- Albendazole with or without surgical removal of the cyst
- Protoscolicidal agent (hypertonic saline) should be injected into the cyst to kill the
organisms or prevent accidental dissemination
Prevention
- Not feeding the entrails of slaughtered sheep to dogs
Trematodes
- Have the greatest impact in terms of number of people infected, morbidity, and
mortality
2 cycles
- Sexual cycle in humans – definitive hosts
- Asexual cycle in freshwater snails – intermediate hosts
- Transmission to humans either via penetration of the skin by the free-swimming
cercariae of the schistosomes or via ingestion of cysts in undercooked (raw) fish or crabs
in Clonorchis and Paragonimus infection

1. Schistosoma (blood fluke)

Disease
- Schistosomiasis
- S. mansoni and S. japonicum – GI tract
- S. haematobium – urinary tract
Important Properties
- In contrast to trematodes which are hermaphrodites, adult schistosomes exist as
separate sexes but live attached to each other
- Humans are infected when the cercariae penetrate the skin; differentiate into larvae
(schistosomula), enter the blood, and are carried via the veins into the arterial
circulation
- Those that enter the superior mesenteric artery pass into the portal circulation and
reach the liver where they mature into adult flukes
- S. mansoni and S. japonicum adults migrate against the portal flow to reside in the
mesenteric venules; S. hematobium reach the bladder veins
- Humans are infected when the cercariae penetrate the skin; differentiate into larvae
(schistosomula), enter the blood, and are carried via the veins into the arterial
circulation
- Those that enter the superior mesenteric artery pass into the portal circulation and
reach the liver where they mature into adult flukes
- S. mansoni and S. japonicum adults migrate against the portal flow to reside in the
mesenteric venules; S. hematobium reach the bladder veins
Pathogenesis
- Most pathologic findings are caused by presence of eggs in the liver, spleen, or wall of
the gut or bladder
- Liver: granuloma leading to fibrosis, hepatomegaly, and portal hypertension leading to
splenomegaly
- Hepatocytes are usually undamaged
- Eggs damage the intestines due to digestion of tissue by proteolytic enzymes
- Eggs of S. haematobium in the wall of the bladder induce granulomas and fibrosis –
bladder carcinoma
- Evade host defenses by coating the surface with host antigens

Clinical Findings
- Asymptomatic, symptomatic with chronic infections
- Acute stage: fever, chills, diarrhea, lymphadenopathy, hepatosplenomegaly,
eosinophilia – resolves spontaneously
- Chronic stage: gastrointestinal hemorrhage, hepatomegaly, massive splenomegaly
- S. haematobium – hematuria; superimposed bacterial UTI are frequent
Laboratory Diagnosis
- Characteristic ova in the feces or urine
 - Moderate eosinophilia

Treatment
- Praziquantel
Prevention
- Proper disposal of human waste and eradication of the snail host
 2. Clonorchis sinensis
Disease
- Clonorchiasis (Asian liver fluke infection)
Important Properties
- Humans are infected by eating raw or undercooked fish containing the encysted larvae;
excysted in the duodenum and enter biliary ducts and differentiate into adults
(hermaphrodite); produce eggs and excreted into the feces
- Upon reaching freshwater, gets ingested by snails (intermediate hosts), hatch within the
gut and differentiate into larvae and into cercariae
- Cercariae encyst under the scales of freshwater fish (intermediate host) and eaten by
humans
Pathogenesis
- Inflammatory response can cause hyperplasia and fibrosis of the biliary tract, but often
there are no lesions
Clinical Findings
- Most are asymptomatic; in patients with a heavy worm burden, upper abdominal pain,
anorexia, hepatomegaly, eosinophilia
Laboratory Diagnosis
- Typical small, brownish, operculated eggs in the stool
Treatment
- Praziquantel
Prevention
- Adequate cooking of fish; proper disposal of human waste
 3. Paragonimus westermani (lung fluke)
Disease
- Paragonimiasis
Important Properties
- Humans are infected by eating raw or undercooked crab meat or crayfish containing the
encysted larvae;
- Excysted in the small intestine, flukes penetrate the intestinal wall, migrate through the
diaphragm into the lung parenchyma
- Differentiate into hermaphroditic adults and produce eggs that enter the bronchioles
and are coughed up or swallowed
- Eggs in either sputum or feces that reach freshwater hatch into miracidia which enter
snails (first intermediate host) and differentiate into larvae and then into cercariae
which infect freshwater crabs (second intermediate host) and then eaten by humans
Pathogenesis
- Within the lung, worms exist in a fibrous capsule that communicates with a bronchiole
- Secondary bacterial infection is common resulting in bloody sputum
Clinical Findings
- Chronic cough with bloody sputum; dyspnea, pleuritic chest pain, recurrent attacks of
bacterial pneumonia; may resemble tuberculosis
Laboratory Diagnosis
- Typical operculated eggs in sputum or feces
Treatment
- Praziquantel
Prevention
- Cooking crabs properly
 Nemathelminthes/Nematodes (Roundworms)
A. Intestinal Nematodes
- Enterobius
- Trichuris
- Ascaris
- Ancylostoma & Necator
- Strongyloides
- Trichinella

B. Tissue Nematodes
- Wuchereria
- Onchocerca
- Loa

Nematodes
- Roundworms with a cylindrical body and a complete digestive tract including a mouth
and an anus
- Have separate sexes; female usually larger than male
- Intestinal nematodes – transmitted by ingestion of larvae; 2 larval forms – 1st and 2nd
stages (rhabditiform) are noninfectious, feeding forms; 3rd stage (filariform) is
infectious, nonfeeding
- As adults, these nematodes live within the human body except for Strongyloides which
can also exist in soil
- Tissue nematodes are called filarial worms because they produce motile embryos called
microfilariae in blood and tissue fluids; transferred from person to person by
bloodsucking mosquitoes or flies
 A. Intestinal Nematodes

1. Enterobius vernicularis
Disease
- Pinworm infection (enterobiasis)
Important Properties
- Infection occurs only in humans; no animal reservoir or vector
- Acquired by ingesting worm eggs; hatch in the small intestine, differentiate into adults
and migrate to the colon and mate
- At night, female migrates from the anus and releases thousands of fertilized eggs on the
perianal skin and into the environment
- Develop into embryonated eggs and become infectious
- Reinfection can occur if they are carried to the mouth by fingers after scratching the
itching skin
Pathogenesis and Clinical Findings
- Perianal pruritus is the most prominent symptom; thought to be an allergic reaction to
the proteins of either the adult female or eggs; predisposes to secondary bacterial
infection
Laboratory Diagnosis
- Eggs are recovered from perianal skin using Scotch tape technique; unlike other
intestinal nematodes, eggs are not found in the stools
 - Small, whitish adult worms can be found in the stools or near the anus of diapered
children
Treatment
- Albendazole, mebendazole, pyrantel pamoate – kill the adult worms in the colon but not
the eggs; re-treatment in 2 weeks is suggested; reinfection very common; household
members should be treated
Prevention
- Washing hands when preparing food and washing bed sheets, towels, diapers, and
clothing to remove eggs
 2. Trichuris trichiura
Disease
- Whipworm infection (trichuriasis) – whiplike appearance
Important Properties
- Humans are infected by ingesting worm eggs in food or water contaminated with
human feces; hatch in small intestine where the larvae differentiate into immature
adults
- Migrate to the colon where they mature, mate and produce eggs and are passed in the
feces; eggs deposited in warm, moist soil form embryos and become ingested
Pathogenesis and Clinical Findings
- Do not cause significant anemia unlike hookworms; may cause diarrhea, but most are
asymptomatic
- May cause rectal prolapse in children with heavy infection from increased peristalsis
that occurs in an effort to expel the worms
Laboratory Diagnosis
- Typical eggs (barrel/lemon-shaped with a plug on each end) in the stool
Treatment
- Albendazole
Prevention
- Proper disposal of feces

3. Ascaris lumbricoides
Disease
- Ascariasis
Important Properties
- Humans are infected by ingesting worm eggs in food/water contaminated with human
feces
- Eggs hatch in the small intestine, and larvae migrate through the gut wall into the blood
stream and then to the lungs; enter the alveoli, pass up the bronchi and trachea, and are
swallowed; become adults within the small intestine, live in the lumen, do not attach to
the wall, and derive sustenance from ingested food
- Largest intestinal nematodes (giant roundworm); thousands of eggs laid daily, passed in
the feces, and differentiate into embryonated eggs in warm, moist soil; gets ingested
Pathogenesis and Clinical Findings
- Major damage occurs during larval migration rather than presence of adult in intestine
- Lungs – eosinophilic exudate occurs in response to larval antigens
- Heavy worm burden may contribute to malnutrition
- Most infections are asymptomatic; ascaris pneumonia – fever, cough, eosinophilia;
abdominal pain and obstruction can result from presence of adult worms in intestine
Laboratory Diagnosis
- Eggs in stools (oval with irregular surface); adult worms occasionally seen in stools
Treatment
- Albendazole, mebendazole, ivermectin
Prevention
- Proper disposal of feces
 4. Ancylostoma duodenale & Necator americanus
Disease
- A. duodenale (Old World hookworm) and N. americanus (New World hookworm) cause
hookworm infection
Important properties
- Humans are infected when filariform larvae in moist soil penetrate the skin, usually the
feet or legs; carried by the blood to the lungs, migrate into the alveoli and up the
bronchi and trachea and then swallowed
- Larvae develop into adults in the small intestine, attaching to the wall with either cutting
plates (Necator) or teeth (Ancylostoma); feed on blood from capillaries of the intestinal
villi
- Thousands of eggs per day are passed in the feces; develop into noninfectious, feeding
(rhabditiform) larvae and then into 3rd stage, infectious, nonfeeding (filariform) larvae
which penetrate the skin
Pathogenesis and Clinical Findings
- Loss of blood at the site of attachment; consumed by the worm and oozes at the site in
response to an anticoagulant made by the worm
- Weakness and pallor accompany microcytic anemia caused by blood loss in patients
whose nutrition cannot compensate for the blood loss
- Ground itch, a pruritic papule or vesicle, can occur at the site of entry of the larvae into
the skin; can also cause cutaneous larva migrans
- Pneumonia with eosinophilia can be seen during larval migration
Laboratory diagnosis
- Eggs in stool; occult blood frequent; eosinophilia typical
Treatment
- Albendazole, mebendazole, pyrantel palmoate
Prevention
- Disposing of sewage properly and wearing shoes
 5. Strongyloides stercoralis
Disease
- Strongyloidiasis
Important Properties
- 2 distinct life cycles – one within the human body and the other free-living in the soil
- Life cycle in the human body begins with penetration of the skin (usually feet), by
infectious (filariform) larvae and migration to the lungs
- Enter alveoli, pass up the bronchi and trachea, and then swallowed; larvae molt into
adults in the small intestine and enter the mucosa and produce eggs
- Eggs hatch within the mucosa forming rhabditiform larvae that are passed in the feces;
some larvae molt to form filariform larvae and penetrate the intestinal wall directly
without leaving the host and migrate to the lungs (autoinfection)
- In immunocompromised patients or with severe malnutrition, autoinfection can lead to
massive reinfection (hyperinfection) with larvae passing to many organs with severe and
fatal consequences
- If larvae are passed into the feces and enter warm, moist, soil, they molt through
successive stages to form adult male and female worms; after mating, entire life cycle
can occur in the soil; after several free-living cycles, filariform larvae are formed and can
initiate parasitic cycle upon contact and penetration of skin
Pathogenesis and Clinical Findings
- Most patients are asymptomatic especially those with low worm burden; watery
diarrhea; pneumonitis similar to A. pneumonia; pruritus can occur at the larval
penetration of the skin, as with hookworm; causes larval migrans
 - Autoinfection – chronic strongyloidiasis: intermittent abdominal pain, fluctuating rashes,
and intermittent eosinophilia; hyperinfection – sepsis caused by enteric bacteria can
occur
Laboratory Diagnosis
- Finding larvae, rather than eggs, in the stool; eosinophilia
Treatment
- Ivermectin; albendazole: alternative
Prevention
- Dispose sewage properly and wear shoes; in immunosuppressive patients, check for
antibodies to Strongyloides – if present, treat with ivermectin
 6. Trichinella spiralis
Disease
- Also called trichina worm
- Trichinosis
Important Properties
- Any mammal can be infected; pigs are the most important reservoirs of human disease;
humans are infected by eating raw or uncooked meat containing larvae encysted in the
muscle
- Larvae excyst and mature into adults within the mucosa of the small intestine; eggs
hatch within adult females and larvae are released into the bloodstream to many
organs; however they develop only in striated muscle cells; encyst within a fibrous
capsule and can remain viable for several years but eventually calcify
- Maintained in nature by cycles
Pathogenesis and Clinical Findings
- A few days after eating undercooked meat, usually pork – diarrhea follows 1-2 weeks
later by fever, muscle, periorbital edema, and eosinophilia
- Subconjunctival hemorrhage – important diagnostic criterion
- Sign of cardiac and central nervous system disease are frequent because the larvae
migrate to these tissues as well
- Death is usually due to congestive heart failure or respiratory paralysis
Laboratory Diagnosis
- Larvae within striated muscle
Treatment
- Steroids plus albendazole can be useful
Prevention
- Properly cooking pork and feeding pigs on cooked garbage
B. Tissue Nematodes
 1. Wuchereria bancrofti
Disease
- Filariasis; elephantiasis is a striking feature of the disease
Important Properties
- Humans are infected when the female mosquito (Anopheles and Culex species) deposits
ineffective larvae on the skin while biting
- The larvae penetrate a skin, enter a lymph node, and after 1 year, mature to adults that
produce microfilariae
- Ingested by biting mosquitoes; microfilariae produce ineffective larvae that are
transferred with the next bite; humans are the only definitive hosts
Pathogenesis and Clinical Findings
- Adult worms in the lymph nodes cause inflammation that eventually obstructs
lymphatic vessels, causing edema
- Microfilariae do not cause symptoms
- Early infections are asymptomatic; later, fever, lymphangitis, and cellulitis – obstruction
leads to edema and fibrosis of the legs and genitalia, especially the scrotum
- Elephantiasis occurs mainly in patients who have been repeatedly infected over a long
period
- Topical pulmonary eosinophilia – characterized by cough and wheezing, especially at
night; caused by microfilariae in the lung that elicit an immediate hypersensitivity
reaction
Laboratory Diagnosis
- Thick blood smears taken from the patient at night might reveal microfilariae
Treatment
- Diethylcarbamazine effective against microfilariae; no drug therapy for adult worms;
doxycycline against Wolbachia (plays a role in the pathogenesis of Wuchereria) results in
a significant decrease in the number of microfilariae in the patient
Prevention
- Mosquito control with insecticides and the use of protective clothing, mosquito netting,
and repellents
 2. Onchocerca volvulus
Pathogenesis and Clinical Findings
- Inflammation occurs in subcutaneous tissue; pruritic papules and nodules form
- Microfilariae migrate and concentrate in the eyes – cause blindness
- Loss of subcutaneous elastic fibers leads to wrinkled skin (“hanging groin”); thickening,
scaling, and dryness of the skin with severe itching (“lizard skin”)
Laboratory Diagnosis
- Biopsy of affected skin reveals microfilariae; eosinophilia
Treatment
 - Ivermectin for microfilariae; suramin for adult worms but is toxic and used particularly in
those with eye disease; skin nodules may be removed surgically but new nodules
develop
Prevention
Control of the blackfly with insecticides; ivermectin prevents the disease

3. Loa loa
Disease
- Loiasis
Important Properties
- Humans are infected by the bite of the deer fly (mango fly), depositing larvae on the
skin; larvae enter the wound, wander in the body and develop into adults
- Female releases microfilariae that enter the blood, particularly during the day
- Microfilariae are taken up by the fly during a blood meal and differentiate into infective
larvae, cycle continues when the fly bites another person
Pathogenesis and Clinical Findings
- No inflammatory response to the microfilariae and adults
- Hypersenstivity reaction causes transient, localized, non-erythematous, subcutaneous
edema
- Most dramatic finding is an adult worm crawling across the conjunctiva of the eye –
harmless but disconcerting
Laboratory Diagnosis
- Visualization of the microfilariae in a blood smear
Treatment
- Diethylcarbamazine eliminates the microfilariae and may kill adults; surgical excision of
worms in the eyes
Prevention
- Control of the fly by insecticides